Week in public services: 1st November 2021

After a short hiatus, I’d like to welcome all readers back to the Week in Public Services. I hope we can be forgiven for our absence and offer up this year’s Performance Tracker as both an excuse and penance. There’s a lot to cover from the last few months so let’s not hang around…

This week: reaction to the budget and spending review; reflection on the Health and Care bill; worries about the elective treatment backlog; response to the adult social care reforms; lost learning recovery; and some other bits and pieces

General

At the IfG we’re still recovering from last week’s budget and spending review — an event described around the office as “Christmas for nerds”. So in true festive spirit, let’s pull the cracker of departmental settlements and dive into the gravy boat of fiscal windfalls:

• The most obvious place to start is with our own “Five things we learnt from the October 2021 budget”
• From there, you can read our own Graham Atkin’s piece in the Times Red Box. If the paywall is causing problems, the tl;dr version is: spending is enough to maintain standards in public services but won’t lead to any improvements or be enough to address the Covid backlog (sorry Graham for butchering your expertly crafted piece)
• The IFS, as always, has an excellent summary, including a full playback of their budget and spending review event
• The King’s Fund published a lengthy blog post about what the budget and spending review mean for health and social care — well worth a read.
• Finally, the Resolution Foundation give its overview of what it’s dubbed the “Boris Budget”

Health and Care

With that behind us, normal business can resume. And where better to start than the reforms proposed by the Health and Care Bill.

One of the key pillars of reform is the rolling out of integrated care systems (ICSs) in April of next year. For those still confused as to how exactly ICSs operate, the King’s Fund has a helpful one page explainer. For even more ICS content, the BMA has this article that looks at what ICSs mean for doctors.

Next up is how the bill reforms funding: this piece from the Health Foundation supports the proposed move away from ‘payment by results’ to the new ‘blended’ approach that combines three types of payments to providers:

1. A fixed element, designed to afford providers some stability, allowing them to plan for the future
2. A variable portion which compensates providers for differing levels of activity
3. A quality-related component to incentivise (surprise, surprise) quality care

The Health Foundation argues that this model should effectively balance competing objectives — such as financial goals and wider population health outcomes — during the upcoming ‘daunting’ (their word, not mine) period for the health service.

This blog post from NHS Providers delivers a more sceptical view of the blended approach, as the author struggles to see how the new payment framework supports the goal of better integrated care.

One final article that’s worth reading on the Health and Care Bill is a July editorial from the BMJ. Two interesting points from this: the first is the contextualisation of the bill in the longer history of the NHS. Striking a rather weary tone, the author draws parallels between the new integrated care boards, strategic health authorities (scrapped during 2012 reforms) and area health authorities (brought into existence in 1974). Second, the increased control over the NHS that the bill gives to the health secretary. While not in and of itself a negative, centralisation of power does seem strange in the context of the government’s levelling up agenda which promises to give regions more control over their public services.

Alright, enough of the Health and Care Bill. Elsewhere, the elective backlog is causing consternation amongst wonks. This piece from Policy Exchange calls the backlog “the number one problem facing the health service” and calls for a number of measures:

• An elective workforce plan (resource constraint on the backlog is something we also flag in Performance Tracker)
• Use of technology to speed up ‘patient throughput’
• Giving patients more information to allow them to manage their patient journey
• Increased productivity within the health service

Two measures that are looked at less favourably are 1. the Health and Care Bill, which Policy Exchange claims could consume administrative capacity; and 2. the use of targets and performance management, which it argues need to be deployed “carefully” — a view that echoes the findings of our paper from earlier this year.

Interestingly, both Policy Exchange and the Health Foundation draw comparisons between the current elective backlog and the waiting times crisis of the early-2000s so it’s worth digging out this Lancet piece from 2007. In it, the author describes the “management by terror” instituted by Blair’s government — a process which sounds unpleasant for NHS chief executives but which did work to drive waiting times down. It should also be noted that the author claims it “demoralised” the workforce — not an outcome that many would welcome after one of the most stressful periods for NHS staff in the service’s history.

That’s a lot about health; let’s take a look at what the reforms mean for adult social care.

Sarah O’Connor paints a vivid picture of care work in 2021 for the FT. Chief among the targets of her ire are zero-hour contracts, poor wages, and the ‘time and task’ model of care commissioning. She points to how these factors are driving carers out of the sector towards less stressful and better paid jobs such as retail (that famously well-paid and stress-free career choice).

This echoes the findings of our Performance Tracker which showed that recruitment and retention in the sector increased during the pandemic, only to decline from April this year. The broader point of her article is a good one — better pay, working conditions and training are needed to attract people into this increasingly important and highly-skilled sector, but this is difficult in the context of ten years of declining grants from central government.

That piece dovetails nicely with the Housing, Communities and Local Government select committee hearing on the topic of long-term funding of adult social care. Like O’Connor, witnesses in this hearing called for a workforce plan for social care and also warned that reforms could cause greater instability among social care providers as local authorities begin to procure care on behalf self-funders. Currently, self-funders pay roughly 40% more for care than those paid for by local authorities. Bad for self-funders, but good for providers and local authorities who use this as an effective subsidy to keep costs low and providers in the market.

So, just to recap, that’s staff shortages and potential provider disruption in the adult social care sector, all while rising demand and an increase in the national living wage push costs ever higher for local authorities. Something about this makes me think the government hasn’t solved the social care crisis ‘once and for all’.

A recurring theme from all of these pieces is the need for a long-term plan for health and care workforces. If you’re pinning your hopes on the NHS People Plan that was due to be published in 2019, I wouldn’t get too excited; this report from the Committee of Public Accounts confirms that we are still waiting for it. Maybe next year.

Children and Young People

Right, deep breath after that wave of information. Hopefully less to cover in this section.

The big discussion in schooling is still lost learning from the pandemic. For those keeping score, a further £1.8bn was allocated to learning recovery at the spending review, bringing the total up to £4.9bn. While welcome, this is still a long way short of the £13.2bn the IfG estimates, the £13bn the Education Policy Institute recommends and the £15bn that Kevan Collins — the government’s own education tsar — advised before he resigned in the summer.

The £4.9bn is a lot closer, however, to the £5.8bn proposed by a group of school leaders at the end of August. This letter proposes that spending should be focused on the most disadvantaged children, who they claim have been most hurt by schools closures.

That point is supported by this report from the IFS which examines the effect of home learning on children’s education. They found that while home learning outcomes improved between the first and second school closures, there was a large disparity between the least- and the most-disadvantaged pupils. The poorest 20% of pupils spent just 19 hours a week on learning activities compared to 27 hours for the richest 20%. As with the above letter, the report recommends using targeted interventions to close the gap after the pandemic.

In other news:

• This article from the Economics Observatory questions how we should measure human capital development in children. The answer is — unfortunately, but perhaps unsurprisingly — ‘with great difficulty’. After eliminating some more esoteric approaches, the authors plump for standardised testing as the ‘best-of-a-bad-bunch’ metric, though heavily caveat this with warnings about the limitations of test scores. Among the factors that influence exam results are month of birth, pollution levels, illness, and — alarmingly for British students — poor weather.
• One of those seemingly technical points with real world impacts — FFT Education Datalab estimates that changes to the pupil premium resulted in a loss of £133m of funding for schools.
• The Policy Innovation and Evaluation Research Unit (PIRU) report on the effect of the pandemic on those with autism. One interesting point is that autistic people struggled to follow rules due to poor and often conflicting government communication. PIRU recommends the publishing of ‘easy-to-read’ guidance to combat this.
• The Competition and Markets Authority released its analysis of the children’s social care market. It has two central concerns:

1. The market is not providing appropriate placements that meet children’s needs
2. Persistently high prices and profits are above what would be expected in a well-functioning market

It does note, however, that part of this is due to the difficulties of predicting demand for children’s services. Unfortunately, this is not something that is likely to change anytime soon, meaning that it will continue to be hard for providers to plan places.

Law and Order

A quieter few months in this section, though there have still been a couple of interesting pieces that are worth flagging.

This report from the Prison Reform Trust looks at women’s experiences of prison during Covid. Its central claim is that the importance of family contact for women in prisons was repeatedly underestimated throughout the pandemic. The last page has a list of practical interventions that should be rolled out in the event of a return to Covid restrictions.

Following the theme, Crest has published its report on the impact of maternal imprisonment. It takes a wider view than the Prison Reform Trust, assessing the cost to society of separating mothers and children. It finds that poor outcomes — such as exclusion from school, mental health issues and crime — are more common amongst children with imprisoned mothers and that the cost to society is large, up to £265k per family with an imprisoned mother.

Local Government

In more spending review content, the LGiU welcomes the increase in central grant funding for local government but notes that much of the increase in core spending power outlined by the Treasury will have to be delivered by council tax rises. It also points out that the increase in the national living wage will add further pressure to council budgets. For more on this issue, David Philips from the IFS has a really good thread showing how the government’s headline spending increases of 3% for local government are split between grant funding, council tax increases and funding from the new social care reform.

Finally, at the nexus of local government, adult social care and justice, comes this report from the Local Government Association which looks at the experiences of people with learning disabilities and autism in the criminal justice system. They recommend the use of the Sequential Intercept Model (SIM) which describes five stages at which interventions can be made to keep those with learning disabilities or autism out of the criminal justice system.

Wrap up

That’s quite a lot covered in our first blog post back in a while — apologies once again to anyone out there who has been feverishly refreshing the page every week for the last few months.

One last piece of housekeeping: even though we are back, the plan is to publish a piece every two weeks. However, in a decision that is likely to enrage the pedants among you, we will not be changing the name of the blog — “Fortnight in public services” just doesn’t have quite the same ring to it.